Ocular Rosacea by Sandra Cremers, MD Presentation Transcript
A Hidden Concern in Ocular RosaceaSandra Lora Cremers, MD, FACS March 2013
Rosacea, Boring and Not Glamorous?
Objectives:1. Describe Epidemiology, Diagnosis,Pathophysiology, and Treatment ofRosacea and Ocular Rosacea2. Discuss Recent Research Finding ofRosacea and Ocular Rosacea3. Discuss Ocular Rosaceas Relationshipto other Angiogenesis Based Diseases
Outline:1. Case Presentations2. Diagnosis and Details3. Observations & Collaborations4. A Hidden Concern
1. Case Presentations
Case Presentation:79 yo white male presents complainingof "poor vision in right eye after cataract surgery. Worse than before the surgery"
Case Presentation:BCVA: 20/50 OD, 20/30 OSExternal exam:
Ultimate Diagnosis: Unhappy patient because he perceived a missed diagnosis ofocular rosacea as the reason for less than expected vision after cataract surgery.
A Brief Historical Perspective
Young Rembrandt Older Rembrandt
2. Diagnosis and Details
A Definition of RosaceaRosacea is a multifactorial, hyper-reactivity, vascular andneural based disease with a broad range of facial andmanifestations where normal vasodilation is greater andmore persistent and involves an autoimmune componentwhere microscopic amounts of extravasated plasma inducelocalized dermal inflammation where repeated externaltriggers lead vasodilation, telangiectasias, redness witheventual fibrosis and hypertrophic scarring of the dermis.
What is Ocular Rosacea and How do you make the Diagnosis?
Epidemiology of Ocular Rosacea:1. In 3-58% of patients with Rosacea2. M=F3. European descent more common4. Starts in 20s and often worsens with age5. Can be seen in kids
Symptoms:1. Burning2. Foreign body sensation3. Dry eye4. Tearing (reflex)5. Eye redness6. Mattering of eyelids
Usual Prevention:● Avoid foods, drinks, and situations that trigger outbreaks like sun● Hat, sunglasses● increase Omega 3s intake
4. A Hidden Concern
Years of Observations of Ocular Rosacea 1. If also had diabetes, tended to develop proliferative diabetic retinopathy 2. If they also had age related macular degeneration (ARMD), tended to develop wet ARMD 3. If they had a corneal transplant, they would tend to have a rejection more often.
A Chance Encounter at Grand Rounds
Who is this man?
Nature. 2009 Jun 25;459(7250):1126-30. doi: 10.1038/nature08062.
Sandra Lora Cremers, MD, FACSHarvard Medical SchoolGrant: National Rosacea Society
Results: Patient 3, CD 31+
Results: Patient 1, CD31+
Results: Patient 1, VEGF+
Doxycycline Magical Properties:1. Anti-Angiogenic at low doses2. Anti-bacterial at higher doses
Central Theory of Rosacea by Sandra Lora Cremers, MD, FACS NGF Neuronal-Driven Angiogenesis PDGFGrants: Harvards 50th Anniversary ScholarsGrant; National Rosacea Society; Lions Eye
Central Theory of Rosacea by Sandra Lora Cremers, MD, FACS Low Oxygen state NGF Neuronal-Driven Angiogenesis PDGF low dose 0.5 mg/kg/d - significantly reduces BV growth & Doxy migrationmitochondrial genes,ER stress cascade,growth factors,interleukins, nitric oxide (NO) synthetasecell cycle regulators,integrins, and componentsof the extracellular matrix;TNF-alpha, IL-10 and Grant provided by National Rosacea SocietyIFNgamma
More Complete Definition of RosaceaRosacea is a multifactorial, hyper-reactivity, vascular andneural based disease with a broad range of facial andocular manifestations where normal vasodilation is greaterand more persistent and involves an autoimmunecomponent where microscopic amounts of extravasatedplasma induce localized dermal and meibomian glandinflammation and where repeated external triggers lead toangiogenesis (the recruitment of new blood vessels),vasodilation, teleangiectasias, redness with eventualfibrosis and hypertrophic scarring of the dermis andmeibomian glands.Likely a central underlying factor in all subtypes of rosacea,particularly ocular rosacea, involves VEGF and similarangiogenic factors.
Future Research For Ocular Rosacea 1. Is Severe Ocular Rosacea due to increased angiogenesis activity at the lid margin? 2. Would they benefit from topical anti- angiogenic medications?
Future Research For Ocular Rosacea 1. Do severe ocular rosacea patients have an increased risk of systemic angiogenesis? 2. Do these patients need to be evaluated for an increased risk of internal tumors or metastasis if primary tumors present?
Recommendations for Ocular Rosacea Patients:1. Avoid inflammatory factors (triggers, sun, smoke)2. Eat antioxidants, Omega 3s,2. If must treat with doxycycline, use lowest doseStart with 20mg q day; 40-mg, controlled release formulationof doxycycline monohydrate is an anti-inflammatory drug3. General medical check ups
Thank you for your attention.
References:1. Rohrich RJ, Griffin JR, Adams WP., Jr Rhinophyma: Review and update. Plast Reconstr Surg.2002;110(3):860–869. quiz,870.2. Scheinfeld NS. Rosacea. Skinmed. 2006;5:191–194.3. Glycomic analysis of tear and saliva in ocular rosacea patients: the search for abiomarker. Ocul Surf. 2012 Jul;10(3):184-92 , Vieira AC, An HJ, Ozcan S, Kim JH,Lebrilla CB, Mannis MJ.2. http://rosacea-support.org/ocular-rosacea-diagnostic-test-one-step-closer.html3.4. Perry HD, Doshi-Carnevale S, Donnenfeld ED, et al. Efficacy of commerciallyavailable topical cyclosporine A 0.05%in the treatment of meibomian gland dysfunction. Cornea. 2006;25:171-1753. Stone, Curr Opin Ophthalmol, 2004http://www.rosacea-treatment.org/6. http://videos.med.wisc.edu/videos/375717. Doxycyclines Effect on Ocular Angiogenesis: an In Vivo Analysis.Ophthalmology 2010 Sept, 117(9): 1782-1791. Cox, C, et al.8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315879/9. Del Rosso JQ, Bikowski JB. Multicenter, doubleblind, randomized, placebo-
References continued:9. Del Rosso JQ, Bikowski JB. Multicenter, doubleblind, randomized, placebo-controlled, parallelgroup trial results evaluating the effects of 40 mgdoxycycline monohydrate controlled-release capsules in the treatment of rosacea.Poster presented at: 64 th American Academy of Dermatology Meeting ; March3–7, 2006; San Francisco, Calif.10.http://www.globalacademycme.com/fileadmin/pdf/supplement_pdf/fczjw6vm_sanews_supplement46.pdf